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The Assessment Process

The Assessment Process. Chapter 11. Assessment as a Process. Deliberate and systematic collection and interpretation of biopsychosocial information or data to determine current and past health, functional status and human responses to mental health problems, both actual and potential.

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The Assessment Process

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  1. The Assessment Process Chapter 11

  2. Assessment as a Process Deliberate and systematic collection and interpretation of biopsychosocial information or data to determine current and past health, functional status and human responses to mental health problems, both actual and potential

  3. Assessment • Initial Assessment • Comprehensive – all data • Screening – Recognize symptoms, risk factors or emotional difficulties. • Ongoing Assessment • Monitor the progress and outcomes of the interventions. • Focused

  4. Techniques of Data Collection • Patient observations • Interviews - patient and family (Text Box 11.2) • Physical examination • Records and diagnostic reports • Collaboration with colleagues

  5. Biopsychosocial AssessmentText Box 11.3: Biologic Domain • Present and Past Health Status • Physical Examination • Body Systems Review • Neurologic Status • Laboratory Results (Table 11.1) • CBC • Electrolytes • Na+, K+ • Renal Function Tests • BUN, Creatinine • Serum enzymes • Amylase, SGOT, CPK • Thyroid Function • T3, T4, TSH

  6. Assessment: Biologic Domain • Physical Functions • Elimination • Activity and exercise • Sleep • Appetite and nutrition • Hydration • Sexuality • Self-care • Pharmacologic • Current and past medications • Over-the-counter, vitamins, herbal supplements

  7. Assessment: Psychological Domain • Responses to mental health problems or consequences • Mental status examination • General observation, appearance, psychomotor activity, attitude • Orientation • Mood, affect, emotions • Speech • Thought processes • Cognition and intellectual performance • Attention and concentration • Abstract reasoning and comprehension • Memory: recall, short-term,long-term (remote) • Judgment and insight

  8. MMSE(Text Box 11.5) • Orientation • Registration • Attention and Calculation • Recall • Language

  9. Assessment: Psychological Domain • Behavior • Self-concept • Body image • Self-esteem • Personal identity • Stress and Coping Patterns • Risk Assessment • Suicidal ideation • Assaultive or homicidal ideation

  10. Suicide Assessment • Have you ever tried to harm or kill yourself? • Do you have thoughts of suicide at this time? • If yes, do you have a plan? • If yes, can you tell me the details? • Do you have the means? • Have you made preparations? Giving things away, etc. • Has a significant episode made you feel this way?

  11. Assaultive or Homicidal Assessment • Do you intend to harm someone? • If yes, who? • Do you have a plan? • If yes, what are the details of the plan? • Do you have the means to carry out the plan? Where is the weapon?

  12. Social Assessment • Functional Status • Social Systems • Family assessment • Cultural assessment • Community support and resources • Spiritual Assessment • Occupational Status • Economic Status • Legal Status • Quality of Life

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